Menopause and Women’s Health

Menopause and Women's Health and Well-being

Menopausal vasomotor symptoms (VMS), (80% report hot flashes and night sweats), sleep disruption (40-56%) and genitourinary syndrome of menopause (GSM) (50%) have a substantial impact on women’s health and overall well-being. Different factors influence the prevalence of VMS, such as climate, diet, lifestyle, women’s roles and attitudes toward the end of reproductive life and aging. Age at menopause is increasingly recognized as a crucial indicator for later-life health outcomes, especially related to estrogen exposure. For example, premature menopause is associated with a reduced risk of breast and ovarian cancers but an elevated risk of cardiovascular disease (CVD) and osteoporosis. Conversely, menopause after the age of 55 is associated with a higher risk of breast cancer but lower risk of CVD and osteoporosis. Additionally, late-onset menopause is associated with a 2% decrease in all-cause mortality for each additional year.

In addition to physical symptoms, menopause can be associated with increased incidence of mental illness. During perimenopause, women may be more prone to depression, with evidence suggesting a positive correlation between VMS severity and depressive symptom manifestations during this transitional period. Since menopause is a stigmatized topic in many regions of the world, most women do not expect the changes to start before the age of 50. As ovarian function declines and reproductive hormone patterns change in their 30s or early 40s, women may be surprised and frightened when they notice such changes; without a way of contextualizing the changes, feelings of anxiety may develop.

Sleep disturbances are prevalent during the menopausal transition as well, and are often attributed to night sweats and psychological factors. Numerous studies indicate that menopause also affects cognitive function, particularly verbal memory and fluency. Although the effect size is unclear, these cognitive changes can be distressing for the women affected.

Psychological Aspects of Menopause

Depression and sleep disturbances affect at least 75% of menopausal women, with perimenopause being a particularly vulnerable period. About 10% of perimenopausal and postmenopausal women experience at least one episode of major depression. Perimenopausal depression typically involves irritability, hostility, agitation and anxiety. Factors linked to psychological symptoms and depressed mood during menopause include prior history of psychological problems, social factors, education, occupation, health, stress, body mass index, smoking and early life experiences. Most women who experience major depression in (peri)menopause have also had major depressive episodes in earlier stages of their lives. Psychological symptoms may also be influenced by beliefs about menopause, impacting self-esteem, VMS and overall stress.

Early menopausal symptoms often include mood changes. Some women report heightened irritability leading to sudden anger, mood swings and increased susceptibility to rage, commonly directed towards close friends and family members. Anxiety-related mood changes such as feeling less capable of coping, increased worry and experiencing panic attacks are also prevalent. The association between mood disorders and sleep problems in (peri)menopausal women has been established, indicating a bidirectional relationship where poor sleep can impact mood and vice versa. Poor sleep is linked to higher levels of anxiety and depression, with mental health concerns identified as significant predisposing factors for sleep-related problems. Additionally, lower educational levels and elevated anxiety levels are associated with severe VMS.

Despite the points made above, it is important to underline that the menopause transition is not universally linked to psychological symptoms in healthy women. Therefore, automatically attributing depressed mood to the menopause transition is not the right approach. Past depression is the primary predictor of depressive symptoms and disorders during menopause. Age is another prominent predictor, with low mood being more prevalent during mid-age; psychological distress tends to rise during adulthood to middle age before declining and leveling off in old age. Later in the menopause, women generally report improvements in mood.

Menopause and Mental Health

Menopause includes a wide variety of psychological and psychosocial changes. Hence, it is important to carefully assess and address these symptoms and provide adequate support. Women in (peri)menopause may experience changes in relationships and social support. Therefore, healthcare providers treating menopausal women should regularly evaluate their patients' current stressors, and the quality of intimate relationships and friendships.

Numerous screening instruments are available for clinicians to assess depression symptoms and their severity in routine evaluations. Although self-rated scales cannot diagnose major or minor depressive disorders, they provide clinicians with insights into the range and severity of symptoms. Women who have experienced major depressive episodes, have severe depressive symptoms or suicidal thoughts should always be evaluated for a mood disorder. In a survey study addressing depression during perimenopause that included 209 physicians, 65.9% reported screening perimenopausal patients for depression. The main barriers for screening were time, inadequate training and inadequate reimbursement, followed by liability concerns, patients withholding information, lack of safe treatments, lack of screening tools, lack of diagnostic consensus and lack of confidence in recognizing depression. However, most of the surveyed physicians were confident in their ability to recognize, diagnose and treat depression. Treatment options for major depressive disorder during menopause include psychotherapy, antidepressant medication, or a combination of both. Estradiol treatment has been shown to be effective as well.

Various factors contribute to the risk of depression, with social factors playing a crucial role in its onset and persistence. Regarding the professional aspect of support, a good patient-clinician relationship and communication should be emphasized. Providers may not always be aware that menopausal symptoms can commence before cycle irregularities, leading to dismissive responses to women's concerns, with some women reporting disappointing healthcare interactions (e.g., being told they are too young for menopausal symptoms).

Support from a woman’s surroundings is also an important part of mental health wellbeing. Some women seek confirmation that their experiences are normal, while others want to understand the connection to hormonal changes. Some women are interested in learning about remedies to alleviate symptoms. Since menopause is a potentially uncomfortable or awkward topic, there is a lack of knowledge sharing across generations (mother to daughter) or between friends. Women without close friends or family to share experiences with often endure these changes alone, especially if cultural norms discourage discussing such matters. Private interactive social media groups have become valuable resources for many women, offering community support and information. These platforms provide a network of shared experiences, bringing relief to women who realize they are not alone or "going crazy". However, women may also be advised to pursue treatments and adopt behaviors that have not been shown to improve outcomes and in some cases cause harm.

Impact of Menopause on Sexual Health

Serum levels of hormones such as testosterone, estrogens, oxytocin, beta-endorphins and prolactin play a crucial role in influencing sexual activity. Estrogens contribute to maintaining tropism and vaginal lubrication, while testosterone stimulates sexual desire. The changes in hormone levels during menopause lead to a series of changes in the urogenital tract, such as shortening and loss of elasticity in the vagina, thinning of the vaginal epithelial layers, reduced secretions and pH changes. As estrogen levels decrease, symptoms such as vaginal dryness, vaginal itchiness, vaginal burning and pain during intercourse emerge, increasing the risk of trauma, discomfort, discharge and infections, particularly during sexual activity. An Australian longitudinal study monitoring women from ages 45 to 55 revealed a significant increase in female sexual dysfunction from 42 to 88 percent during the early to late menopausal stages.

Many women report a decrease in libido and alterations in sensitivity during menopause. Hormone deficiency may directly contribute to this decline, although a shift in self-image leading to reduced self-esteem and anxiety caused by painful intercourse and postcoital bleeding also play a part. Testosterone levels tend to decrease in the blood after the age of 40. Alterations in body shape, weight gain and psychological changes may negatively impact the sense of attractiveness. Depression and anxiety disorders, further influenced by menopausal changes in mood and sleep disturbances, can also contribute to a decline in sexual desire. All of these factors, along with symptomatic vulvo-vaginal atrophy, can significantly influence both central and peripheral sexual response.

Menopause and Quality of Life

Menopausal changes may impact the quality of life (QoL) of a woman experiencing perimenopause and early menopause. While some aspects of QoL might show improvement post-menopause, numerous cross-sectional and longitudinal studies show the adverse effects of menopausal symptoms on QoL. The severity of these symptoms serves as a key indicator of the QoL dimensions.

Several instruments are available to measure QoL during menopause, each covering specific domains (Table 1-1). Generic instruments focus on assessing general physical, social and psychological aspects that affect QoL. Menopause-specific instruments include different scales and questionnaires addressing various domains related to physical, psychological and sexual aspects during menopause. The last set of instruments are the symptom-specific instruments that offer focused assessments of menopausal symptoms, VMS and sexual activity, respectively.

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Understanding how menopausal transition per se (i.e., without the general effects of aging) affects a woman's health and overall QoL poses a challenge for research. When factors like age, life events and socioeconomic status are adjusted for, there appear to be menopause-specific decreases in perceived physical health and psychosomatic well-being. These changes are more pronounced with a longer perimenopause, leading to a greater need for medical attention. The key contributors to QoL decline are VMS and urogenital symptoms. In the Study of Women’s Health Across the Nation, which assessed approximately 3,000 women, several menopausal symptoms, including hot flashes, night sweats, vaginal dryness and urinary incontinence were linked to decreased health-related QoL.

The impact of VMS on QoL is often underestimated. However, seeking help for these symptoms is crucial since they can disrupt work, daily activities and sleep, consequently affecting personal and family life. They can lead to fatigue, difficulty concentrating and mood changes. A significantly higher rate of presenteeism and overall work impairment was reported in women experiencing menopausal symptoms compared to those without such symptoms. The same women suffered higher impairment in daily activities and more physician visits in the past six months. Another study revealed increased work loss, a higher number of medical visits and significantly higher healthcare costs in women with untreated hot flashes compared to asymptomatic women. A different study demonstrated that the frequency and severity of hot flashes strongly affect sleep parameters. Similarly, insomnia also plays an important role in QoL decline during menopause. Furthermore, one study found that experiencing any VMS was associated with decreased QoL; depression and obesity amplified this association.

In terms of psychosomatic symptoms, depression, anxiety, heart racing and forgetfulness have a significant impact on individuals' overall well-being, daily functioning and QoL. Urogenital symptoms, including a lack of desire and arousal, can lead to sexual avoidance, relationship deterioration and an acceptance of sexual decline, further influencing overall QoL during the menopausal transition.